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A Detailed Analysis of the Process and Content Components of the Lifestyle Redesign® Intervention

Dr. Florence Clark, PhD, OTR/L, FAOTA

OverviewHealthy Aging

Development of the Lifestyle Redesign® Intervention

Implementation of the Lifestyle Redesign® Intervention

Healthy Aging

Advice Through the Ages

44 B.C.E.• Cicero

1214-1294• Roger

Bacon

1484-1566• Luigi

Cornaro

1558-1609• Andre du

Laurens

1903• Sir Herman

Weber

Longevity – 44 B.C.

“We ought to take due care of our Health, and to eat and drink sparingly, and use moderate exercise, that we may be enlivened, and have fresher spirits, not be oppressed, and overloaded.”

Powers of the mind “become more refreshed and invigorated the more they are used.”

- Cicero, A Dialogue On Old Age, 44 B.C.

Longevity – 1500’s

“Nothing hastens old age more than idleness.”- Andre du Laurens (1558-1609)

“A temperate life would enable the body’s finite supply of vital spirits to last until life ebbed peacefully away between the ages of five and six score.”

- Luigi Cornaro (1464-1566)

Longevity – 1903 A.D.

“By moderation and abundant exercise of body and mind, including walking, climbing and breathing exercises, I have escaped death from these causes, have greatly prolonged my life, and am now in good health in my 91st year.”

– Case Study from Sir Hermann Weber, On Means for the Prolongation of Life, 1903

Longevity - 2000

“Heath risks such as smoking, physical inactivity, being overweight or obese, consumption of high fat diets, and inadequate fruit and vegetable intake are major determinants of morbidity and mortality.”

Robert Butler, M.D., founder, International Longevity Institute, founding director of the U.S. National Institute on Aging, Pulitzer Prize winner, gerontologist

The White Queen/Tudor Period (Mortality)

Name Age at Death • Elizabeth Woodville (White Queen) 55• Edward IV (White Queen’s husband) 41• Elizabeth of York (White Queen’s daughter) 37 • Margaret Beaufort (Red Queen) 66• Richard Neville (The Kingmaker) 42• Anne Neville (Kingmaker’s Daughter) 28• The Tudors

– Henry VII (Red Queen’s son) 52– Henry VIII (Henry VII’s son) 55– Elizabeth I (Henry VIII’s daughter) 69

Life Span of the Tudor Queens

Birth Age Married Age of Death Cause

Catherine of Aragon 1485 24 51 Executed

Anne Boleyn 1504 29 32 Executed

Jane Seymour 1508 28 29 Died

Anne of Cleves 1515 25 42 Died

Kathryn Howard 1521 19 21 Executed

Catherine Parr 1512 31 36 Died

Life Expectancy Today

US: 78.74 yearsIsrael: 81.7 yearsJapan: 83.1 years

Source: World Bank, 2015

Composing a Further Life:The Age of Active Wisdom

• Traditional Age - Groups– Childhood– Parenthood– Grandparenthood

• Adulthood I– Very busy, productive time, building careers, raising

children

• Adulthood II– Stage of active wisdom preceding old age

From: Bateson, M. C. (2010). Composing a further life: The age of active wisdom. New York: Vintage Books.

Composing a Further Life:The Age of Active Wisdom

Adulthood II

Long lives, Better health

Freedom from work

and raising a family

Rich Experiences

Wisdom combined

with activity

Adulthood II is an “improvisational art

form calling for imagination and the willingness to learn”

From: Bateson, M. C. (2010). Composing a further life: The age of active wisdom. New York: Vintage Books.

What do older adults believe contribute to their health and well-being?

• Reichstadt et al. (2007) found that older adults attribute successful aging to these factors:– Positive Attitude and Adaptability to Change– Sense of Security and Stability– Overall Health and Wellness– Engagement and Stimulation

From: Reichstadt, J., Depp, C. A., Palinkas, L. A., Folsom, D. P., & Jeste, D. V. (2007). Building blocks of successful aging: A focus group study of older adults' perceived contributors to successful aging. The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 15(3), 194-201.

What factors have economists identified that influence

happiness over the life span?

Easterlin, R.A. (2006). Life Cycle Happiness and Its Sources: Intersection of Psychology, Economics, and Demography. Journal of Economic Psychology/ Elsevier, pp. 463-482.

How are gerontologists conceptualizing the

complexity of factors that contribute to healthy aging?

Agency(Life Choices)

Structure(Life Chances)

Lifestyle

Hendricks, J. & Hatch, L.R. (2006). Lifestyle and aging. In R. Binstock & L.K. George (Eds.) Handbook of aging and the social sciences (5th ed., pp. 301-319). San Diego, CA: Academic Press.

The Model on Agency and Structure

• Genetics• Staying active• Lifelong learning• Optimism / Love of Life

Helen “Happy” Reichert with her caretaker

• Kahn Family – All four siblings lived to be centenarians!

• Helen “Happy” Reichert, 108• Irving Kahn, 104• Peter Kahn, 100• Lee Kahn passed away in 2005 at the age of 102

Helen Reichert & Irving Kahn in Time Magazine

Aging Around the World

Okinawan Secrets

Hippocratic Medicine

Traditional Chinese

Medicine

Seventh-Day Adventists

Sardinia

Okinawan Secrets: Japan• Traditional Okinawan diet

– Low in fat and calories– High in carbohydrates (e.g. vegetables, grains)

and nutrients– Lots of vegetables, tofu, seaweed, tea

• Modern fast food invasion…– Increased caloric consumption– Lost #1 life expectancy ranking in Japan

• Low stress and rigorous physical activity

• Moai - a support network providing financial, social, and emotional help throughout life

• Ikigai – a reason to wake up in the morning

Average life expectancy• Female: 87 years• Male: 79 years (among longest in the world)US Average Life Expectancy = 78.8 years

So how can we optimize the chances of staying healthy

during Adulthood II?

Identified a need for in-depth qualitative research to gain critical insights about the needs of the participants and inform protocol refinements

The Qualitative Domain Study• Documented the life

domains and adaptive strategies used by older people living in the setting from which the RCT sample would be drawn

• Provided a rich database to guide tailoring of the intervention protocol

Task Analysis - Mapping the Well Elderly Intervention

• Czaja, Schulz, Lee, C. C., & Belle (2003)• Jackson, Carlson, Mandel, Zemke, & Clark (1998)

Theories:Occupation as Emergent, Dynamic Systems, Meaning through Occupation, Humans as

Occupational Beings

Objective #1:Enhance the selection of

occupations

Key Activities:- Increased occupational balance- Heightened flexibility- More overt strategizing

Objective #2:Enhance the experienced meaning of occupations

Key Activities:- Enactment of flow- Improved connections to life course- Enhanced meaning in daily routine

Treatment Outcomes:Primary Outcomes: Enhanced physical health, Improved mental health, Superior

occupational functioning, and Increased life satisfaction

Adopting a Healthy Lifestyle Later in Life

After only 4 years, adopting a healthy lifestyle in middle age can:

• Reduce mortality risk by 40% • Reduce cardiovascular disease risk by 35%

Theme:

We become what we have done

Break

Development of the Lifestyle Redesign® Intervention

Research Base

Hoffman, T., Bennett, S. & Del Mar, C. (2010). Introduction to evidence-based practice. In T. Hoffman, S. Bennett & C. DelMar (Eds.). Evidence-based practice across the health professions, pp. 1-15. Elsevier Australia: Chastswood, NSW.

EVIDENCE-BASED PRACTICE IS…

…the integration of:

• the best research evidence• clinical expertise• the client’s values and circumstances• the practice context

Why is Evidence-Based Practice Important?

• Evidence-based practice promotes:– The most effective care– Improved outcomes– An attitude of inquiry– Professional accountability – Appropriate use of resources

Hoffman, T., Bennett, S. & Del Mar, C. (2010). Introduction to evidence-based practice. In T. Hoffman, S. Bennett & C. Del Mar(Eds.). Evidence-based practice across the health professions, pp. 1-15. Elsevier Australia: Chatswood, NSW.

USC Division of Occupational Science and Occupational Therapy

Well Elderly Research Program

The USC Well Elderly Studies1994-1997: Well Elderly 1 Study

National Institute on Aging (R01 AG11810, R01 AG11810-03S1)NIH, AHCPR, NCMRR

American Occupational Therapy Foundation (NNPUBS-068-98)PI: Florence Clark, PhD, OTR/L, FAOTA

2004-2008: Well Elderly 2 StudyNational Institute on Aging (R01 AG 021108)

PI: Florence Clark, PhD, OTR/L, FAOTA

Florence Clark, PhD Occupational TherapyRuth Zemke, PhD Occupational TherapyJeanne Jackson, PhD Occupational TherapyMichael Carlson, PhD Social PsychologyLoren G. Lipson, MD Geriatric MedicineStanley P. Azen, PhD Preventive Medicine, BiostatisticsJoel W. Hay, PhD Pharmaceutical Policy & EconomicsBarbara J. Cherry, PhD Cognitive PsychologyDeborah Mandel, OTD Occupational TherapyKaren Josephson, MD Geriatric Medicine

USC Well Elderly 1 Study (WE1) Team

Florence Clark, PhD Occupational TherapyJeanne Jackson, PhD Occupational TherapyStanley P. Azen, PhD Preventive Medicine, BiostatisticsChih-Ping Chou, PhD Preventive MedicineBarbara J. Cherry, PhD Cognitive PsychologyMaryalice Jordan-Marsh, PhD NursingBrett White, MD Family MedicineDouglas Granger, PhD Biobehavioral Health, Penn State Robert Knight, PhD Psychology, GerontologyMichael Carlson, PhD Social PsychologyRand Wilcox, PhD Psychology, StatisticsDeborah Mandel, OTD Occupational TherapyJeanine Blanchard, PhD Occupational Therapy

USC Well Elderly 2 Study (WE2) Team

Well Elderly Study 2: Intent-to-Treat ResultsTreatment (n=187) vs. Control (n=173)

Health Related Quality of Life (SF36V2)

Mental Health 0.03

Social Function 0.04

Vitality 0.03

Bodily Pain 0.02

Composite: Mental 0.03

Composite: Physical 0.09

General Health 0.25

Physical Function 0.09

Role Physical 0.18

Role Emotional 0.16

Life Satisfaction (LSI-Z) 0.03

Depression (CES-D) 0.03

Cognition

Memory (CERAD)

• Immediate Recall 0.20

• Delayed Recall 0.38

• Recognition 0.26

Visual Search 0.49

Psychomotor Speed 0.49

Lifestyle Redesign® Intervention

Lifestyle Redesign®

Lifestyle Redesign® enables patients to design, practice,

and ultimately enact a personalized, sustainable

health-promoting daily routine that is tailored to address

chronic disease risk factors as well as promote health and well-being more generally.

• Can be delayed, even prevented, through lifestyle changes– Coronary heart disease– Certain cancers– Diabetes– Dementia– Arthritis

Age-related Diseases

Lifestyle Redesign

Awareness of Activity Patterns Analysis of Activity Patterns

Changing Habits and RoutinesDevelopment of a

Personalized Engagement Plan (PEP)

Lifestyle Redesign Process

Key Ideas of the Lifestyle Redesign Program

1. Experience in occupation produces radiating, not linear, change.

2. Occupational self-analysis is possible.

3. When people understand occupation, they can redesign their lives.

4. Occupation is the impetus that propels people forward.

5. Active coping is a learned skill that can positively affect well-being.

Occupation Produces Radiating, Not Linear, Change

New sense of social

connectedness

New transportati

on skills

New positive self-image

What changes occur when a participant tries public

transportation for the first time?

Occupational Self-Analysis Is Possible

Who are you as an occupational being?

What occupations do youlike best?

Are you experiencing occupational deprivation?

How do your occupations affect your health?

What is your plan for healthier living? How will you enact your plan?

Lifestyle Redesign Provides a Valuable “Toolkit”

“Toolkit” of Lifestyle Redesign

1) Purposeful selection of health-promoting

occupations

2) Experienced meaning

Occupation Propels People Forward

Technique Occupational Storytelling Occupational Storymaking

Collaboration Evoking stories of occupation Occupational coaching• Encouraging positive remake• Offering occupational

strategies• Reaffirming and marking

progress

Building Empathy Analysis and synthesis• Time• Value

Evoking insight (problems and solutions)

Inclusion of Ordinary • Joint task interaction with self-interest manifested

• Identify and meet group norms and goals

Broadened view of activities of daily living• Handling emotion• Friendship and intimacy• Symbolic dimension of

occupation

Listening Image reconstruction

Reflection Cultural place

Occupation Propels People Forward

Active Coping Is a Learned SkillThe Stress Response

The Transformative Process of Lifestyle Redesign

Conceptual Foundation

• Occupation is essential for human existence• Occupation is transformational• Occupations vary in their degree of

meaningfulness (and positive or negative impact on health)

• People can reorder their occupational patterns from disequilibrium to stability (dynamic systems theory)

Mechanisms of Change

Knowledge Acquisition

Internalization

Habit Formation

Goals of Lifestyle Redesign®

• Assist each participant to develop:– A personally feasible, healthy lifestyle

– Sustainable within the fabric of his or her everyday routines

• Increase or maintain:– Independence

– Health

– Well-Being

Awakening

“I wouldn’t have done itif it weren’t for you!”

• Becoming hyper-cognizant of activity patterns and their impact on health

• Activity Pattern Analysis

• Lifestyle Redesign®

Lifestyle Redesign® Intervention

Knowledge: Understanding the Impact of Activity on Health

• Notice and name activities

• Explore the dimensions of activities– Physical, cognitive, social, emotional & spiritual

• Learn the relationship of activities to health and well-being

• Experience the relationship of activities to health and well-being

Activity Pattern Analysis

• Self-reflect

• Identify barriers

• Identify options and alternatives

Potlucks

Writing

MeditatingRemembering the old

days

Dancing

Going to Church

Exercising

Praying

Reading the Newspaper

Doing Puzzles

Walking

Singing

Parties

El Grupo de Bienestar:Naming Occupations

WellnessMental

Social

Emotional

Spiritual

Physical

Dimensions of Wellness

Developed by El Grupo de Bienestar

Read the NewspaperWritePuzzles

Remember the old daysYogaReadingMusicMeditation

ChurchMassPray

WalkDanceSingExercise

PartiesPotluckDancing

Mental

Social

Spiritual

Physical

Emotional

Wellnessand

Occupation

Developed by El Grupo de Bienestar

Lifestyle Redesign®

• Select personalized healthy activity options

• Make changes in routines

• Practice habits and routines

Preliminary Individual Assessment Investigate: • Medical history• Current daily routines • Functional limitations• Occupational history• Barriers and support systems• Time use/energy management• Stress management• Leisure interests• Long term goals • Diet/exercise

The Personal Engagement Plan (PEP)

Customized to fit the participant’s• Attitudes• Needs• Preferences• Capacities• Environmental

facilitators and constraints

• Health profile

My Life

My Attitudes

Other Key Information

My NeedsMy Health Status

My Behaviors

Making Health Habits and Routines Permanent

Sustainable, healthy routines are a main objective of the Lifestyle Redesign program

Performed somewhat automatically

Provide daily structure

Can counteract the development of chronic disease and disability

Factors that Influence Habits and Routines

Habits and

Routines

Environment

Social support

Financial security

Sleep patterns

Influential people

Biological factors

Others

Adapting Habits and Routines

• Reexamine goals and routines periodically, and adjust when necessary• Include caregivers in habit formation and goal setting• Encourage flexibility and set expectation that plans will be modified over

time

Intervention Delivery

• Didactic Presentation

• Peer Exchange

• Direct Experience

• Personal Exploration

• Personal goals

• Build new habits

• Traditional occupational therapy

• Reinforce and individualize materials from group sessions

Group Meetings Individual Sessions

USC Well Elderly Program ModelContent Areas

Aging, Health, and OccupationTransportation

Safety

Dining

Physical and Mental Activity

Relationships

Cultural Awareness

Finances

Integrative Summary

Methods of Delivery

Group and Individual

Didactic Presentation

Peer Exchange

Direct Experience

Personal Exploration

Health Related Outcomes

Enhanced Physical Health

Superior Occupational Functioning

Increased Life Satisfaction

Modules Utilized in WE1• Occupation, Health, and Aging• Transportation and Occupation• Health Through Occupation: Physical and Mental

Activity• Dining as Occupation• Time and Occupation• Home and Community Safety• Relationships and Occupation• Outings, Exploration, and Special Events• Ending a Group

Program Adaptations (WE1 WE2)• Intervention shortened from 9 months to 6

months• More diverse participants• Research sites expanded to include senior

centers and 1 continuous care retirement community

• Modules were updated and modified

Lunch

Implementation of the Lifestyle Redesign® Intervention

How to Use the Modules

Occupation, health, and aging

Community mobility, transportation, and

occupation

The building blocks of longevity: physical,

mental, spiritual, social, and productive activity

Stress and inflammation management

Dining and nutrition Time and occupation Home and community safety

Relationships and occupation

Thriving Navigating health care Hormones, aging, and sexuality Ending a group

Module 1: Occupation, Health, and Aging

• Goals – Enable participants to:– Describe occupation (homeostasis, routine,

balance, circadian rhythms)– Understand the relationship of occupation to

health and apply concepts in their own lives– Develop their individual preliminary Personalized

Engagement Plans (PEP)

Module 2: Community Mobility, Transportation and Occupation

• Goals – Enable participants to:– Develop an understanding of mobility challenges– Plan and enact solutions to challenges in

preparation for community outings• Focus varies depending on population

– Driving– Public transportation– Having multiple options

Module 3: The Building Blocks of Longevity: Various Types of Activity

• Goals – Enable participants to:– Understand that health and wellbeing requires engagement in a

diverse range of meaningful and health-promoting activities (in addition to avoidance of illness)

– Employ practical approaches for incorporating healthy occupations into daily lives

– Recognize different types of activity:• Physical• Mental• Spiritual• Social• Productive

– Utilize strategies for dealing with factors that impede activity engagement (e.g., urinary incontinence)

What is Occupation?

30% engage in sexual activity at least once per month

Cognitive

Physical

Social

Productive

Spiritual

Module 4: Stress and Inflammation Management

• Goals – Enable participants to:– Understand the relationship of stress and sleep

deprivation on inflammation– Recognize the impact of stress on their minds and

bodies and explore healthy ways to decrease stress– Utilize active coping

• Problem-focused coping– Acting– Planning– Suppressing distracting activities

– Develop strategies for managing sleep

Heckhausen & Schulz (1995), Schulz & Heckhausen (1996)

Homeostasis and Occupation

Homeostasisis a state of balance within the body.

Sometimes we use occupation to help achieve homeostasis.

Circadian Rhythm and Occupation

Module 5: Dining and Nutrition• Goals – Enable participants to:

– Describe what constitutes “healthy eating”– Recognize the relationship of food intake to

activity engagement– Engage in a group cooking and dining activity

based on themes of nutrition and understanding food labels

– Explore the social dimension of eating– Enact methods for organizing medication intake

according to a schedule

Module 6: Time and Occupation• Goals – Enable participants to:

– Analyze their lives in terms of pace, past, present, anticipated future, and degree of forward progression

– Reflect upon the experience of time– Implement strategies for taking control of time

through activity orchestration/management– Chart circadian rhythms

Module 7: Home and Community Safety

• Goals – Enable participants to:– Explore small changes that could prevent an unwanted

attack or improve personal safety at home and in community

– Take appropriate risks, develop friendships, and use available resources to be more comfortable exploring community

– Modify their home environments to eliminate hazards and to promote safe activity engagement

– Employ strategies for fall prevention

Module 8: Relationships and Occupation

• Goals – Enable participants to:– Explore the topics of community and

communication and the impact of loneliness on health

– Discuss cultural and personal strategies for coping with loss or death and dying

– Recognize the importance of end-of-life planning

Module 9: Thriving

• Goals – Enable participants to:– Recognize and exercise their own potential by

• Exploring what they care about most• Engaging in life more profoundly• Discovering their deepest priorities and potentials• Pursuing new forms of meaning

Module 10: Navigating Healthcare

• Goals – Enable participants to:– Increase their health literacy by reviewing and

discussing pertinent content which has been tailored to the particular healthcare system concerns of their group

Module 11: Hormones, Aging, and Sexuality

• Goals – Enable participants to:– Understand the effects of aging on hormones and

sexuality for both men and women– Discuss lifestyle, social, and pharmacological

factors affecting sexuality in later life

Module 12: Ending a Group – Finalizing Personal Engagement Plans (PEPs)

• Goals – Enable participants to:– Finalize their PEPs

• Health promoting habits, routines, and strategies for sustaining enactment of plan over time

– Engage in a ritual/ceremony which marks their transition to a healthy lifestyle independent of group involvement

Personal Engagement Plan (PEP) Select Content Recommendations

for Participants

Plans must be customized to be sustainable

But they should include these components…

1. Learning to listen to your body

• Follow your circadian rhythms• Become mindful of when you are at

homeostasis• Use technology to track your biomarkers

and activity pattern

From: Agus, D. B. (2011). The end of illness. New York: Free Press.

• Through simple everyday practice– i.e., avoid wearing high heels, carrying heavy

purchases, wearing uncomfortable or binding clothes, using heavy suitcases, etc.

2. Trying to avoid chronic inflammation

From: Agus, D. B. (2011). The end of illness. New York: Free Press.

• As much as possible, try to eat…– On a regular schedule– Cold water fish (i.e. trout, tuna, halibut) 3x

per week– A multi-colored diet– Red wine (if you wish) 5 nights per week

• Unless you are at high risk for cancer

– A good-fat diet– Natural, non-processed food

3. Trying to eat a healthy aging diet

From: Agus, D. B. (2011). The end of illness. New York: Free Press.

• Some stress is normal and adaptive• Chronic stress is health-compromising

– Becoming aware of sources of chronic stress is important• Ways of managing stress:

– Finding ways to rest– Avoiding chronic stressors (as much as possible)– Spacing– Taking breaks– Just saying no– Escape– Personal therapeutic activities that are enjoyable, soothing

4. Minimizing your stress

From: Agus, D. B. (2011). The end of illness. New York: Free Press.

• Genetic risk factors – Predisposition to common conditions

• Lifestyle factors can counteract these risks– Physical exercise changes gene expression

5. Knowing your risk factors

From: Agus, D. B. (2011). The end of illness. New York: Free Press.

• Eat, sleep, and exercise at predictable times every day

• Engage in the social, productive, and spiritual activities you value

• Choose physical activities you enjoy (as much as possible)– Consistent physical activities such as walking or

dancing can be very health-promoting • Take time to rest• Avoid sedentary activity as much as feasible

6. Incorporating health-promoting practices

From: Agus, D. B. (2011). The end of illness. New York: Free Press.

• Explore what you care most about– Engage in life more profoundly– Explore your deepest priorities and potentials– Pursue new forms of meaning

7. Developing in new ways

From: Bateson, M. C. (2010). Composing a further life: The age of active wisdom. New York: Vintage Books.

• Taking action is self-perpetuating

8. Getting started

From: Agus, D. B. (2011). The end of illness. New York: Free Press.

What’s really happening in those

groups?

Safe Place

Someone was there to trust.

You will love us, accept us, who we are.

You can make mistakes.

There will be no judgment.

Affirmation that they were on a journey

together.

You did your best to get us where to be.

We could be ourselves.

Touched each other in different

ways.

Talked to each other.

There was nowhere they could talk at this level.

They grew and changed as a

person.

They experienced it and no one can take

that away.

So what did the intervention provide overall?

Lifestyle Redesign®

• Select personalized healthy activity options

• Make changes in routines

• Practice habits and routines

References• Bateson, M. C. (2010). Composing a further life: The age of active wisdom. New York: Vintage

Books.• Easterlin, R.A. (2006). Life Cycle Happiness and Its Sources: Intersection of Psychology, Economies,

and Demography. Journal of Economic Psychology, 27, 463-482.• Heckhausen, J. & Schulz, R. (1995). A life-span theory of control. Psychological Review, 102, 284-

304. • Hendricks, J. & Hatch, L.R. (2006). Lifestyle and aging. In R. Binstock & L.K. George (Eds.) Handbook

of Aging and the Social Sciences (5th ed., pp. 301-319). San Diego, CA: Academic Press.• Jackson, J., Carlson, M., Mandel, D., Zemke, R., & Clark, F. (1998). Occupation in lifestyle redesign:

The Well Elderly Study occupational therapy program. American Journal of Occupational Therapy, 52, 326-336.

• Reichstadt, J., Depp, C. A., Palinkas, L. A., Folsom, D. P., & Jeste, D. V. (2007). Building blocks of successful aging: A focus group study of older adults' perceived contributors to successful aging.The American Journal of Geriatric Psychiatry: Official Journal of the American Association for Geriatric Psychiatry, 15(3), 194-201.

• Schulz, R., & Heckhausen, J. (1996). A life span model of successful aging. American Psychologist, 51, 702-714.

Thank you!